PERRY SHAN: What I'm going to talk about is something, one of the newer surgical techniques that we're involved with in our liver pancreas program. And that's a minimally invasive liver surgery and where we're at. Currently, liver surgery-- as we're going to move into talking about liver disease-- is resection of liver tumors as indicated, just briefly for patients with colorectal liver metastasis. So metastatic colon cancer that's spread to the liver, hepatocellular carcinoma, primary liver cancer, metastatic neuroendocrine tumors, cholangiocarcinoma, so bile-duct tumors that may be in the liver. As well as those-- as Dr. Clark talked about-- that are at the biliurhilum. As well as for selected patients with metastatic disease from other sites that we see on a case by case basis can include kidney, ovarian, breast, sarcoma, GI stromal tumors, melanoma, just to name a few. So I'm not going to talk about that indication, but more that we do liver surgery for these type of patients. What I am going to go through is a background on what the indications are, some background indications for minimally invasive liver surgery, and what are some of the current outcomes for minimally invasive liver surgery in the literature, and then talk about our experience and currently what we've been doing over the past few years in this area. Of course, minimally invasive surgery, or laparoscopic surgery, has revolutionized a lot of the way we do many common operations, gallbladder surgery, bariatrics. The first laparoscopic liver resection was done in 1992 and that was reported by French surgeon Gagner in Surgical Endoscopy. And then another French surgeon, Cherqui, presented his data in 2000 following up on that, looking at the feasibility of laparoscopic liver resection. And really from there, it began to take on more adoption at academic medical centers. And bottom line, what's the main difference with laparoscopic liver surgery versus open? It's really the incision. So traditional liver surgery takes a very large incision to get to the liver for the exposure. And if you're doing a minimally invasive liver surgery, they get a smaller incision. Really, what it requires is some expertise in liver surgery and some expertise in minimally invasive, or laparoscopic, liver surgery techniques. And just a brief primer on the liver anatomy is the liver has eight segments. And this just shows you that the right lobe is-- or left lobe is segments II, III, and IV. The right lobe is V, VI, VII, and VIII. And this is just the underside. Segment I is the caudate is on the under surface. When we talk about classifications of liver resection, there is minor and major hepatectomy. A minor hepatectomy is generally when you're taking less than three segments are removed. A major hepatectomy is when you're removing three or more segments of the liver. And that can include a left hepatectomy, or a right hepatectomy, or even an extended-- which is a right plus a couple more segments-- or a left, plus a couple segments from the right. Also when we talk about laparoscopic liver resection, or minimally invasive, there's been a designation that when you're dealing with segments that are up in the central, or posterior, part of the liver, then you're dealing with-- it's actually a major resection from a laparoscopic point of view. So what are some of the advantages and disadvantages of minimally invasive liver resection? Well, certainly you can have less post-operative pain, decreased post-operative complications-- and we'll go over some of the literature-- potentially the benefit of a shorter hospital stay, and there can be improved cosmesis, decreased hehernia rate, and hopefully a quicker return to normal activities. And in patients who require adjuvant therapy, a quicker initiation of adjuvant, chemotherapy, or chemoradiation therapy. What are some of the disadvantages? Some of the disadvantages can include, if you're doing it laparoscopic, -- you don't have as much of a tactile sensation. There's always a question are you going to get good margins on your tumor? Can you assess for other disease, perineal disease? How do you stage these patients? Also the access, of course, is limited. The instrumentation, is you're not right on the tumor, and are you getting the full exposure? Can you control bleeding when you get into doing these laparoscopic resections? What is the length of the procedure? And are the costs more? This just describes some of the different approaches. Just again, don't want to get too technical here, but since we are talking about a procedure, there's different approaches for what is a laparoscopic or minimally invasive. Laparoscopic alone is when you're just using the instruments alone. So it's just ports, instruments, doing the resection. Laparoscopic-assisted is when you put a hand port in at the bottom, in addition to laparoscopic instruments. So the hand gives you some ability to compress the liver, to provide a tactile sensation through a smaller hand port. Other option is a laparoscopic hybrid where you actually mobilize and free up the liver but you do the surgery outside the abdomen. So you make a smaller incision than you normally would and you do the resection outside the abdomen. But you do a lot of the freeing up, mobilization laparoscopically. And then the newer approach robotic resection-- we'll talk a little bit about that-- using the robot to do a surgery, and that's another way you can do a minimally invasive resection. There's been a couple International Consensus Conferences looking at the role of liver resection, or laparoscopic liver resection, and what are the guidelines. And what they found is that these experts decided that doing a minor resection, or a minor of couple segments or fewer, really nowadays with the experience and the expertise of different centers can be considered really standard practice. And that this is very acceptable. And I'll go over some of the data on these outcomes. It's really more on the peripheral segments of the liver. Now doing major resections, doing major hepatectomy, three or more segments, is still considered really more innovative. It's still in development, being studied. And it's not as commonly done as the minor resections. Now looking at some of the outcomes, because colorectal cancer liver mets is a very common ideology we operate on. There was a study looking at outcomes from three US and two European centers, about 100 patients over a eight year period. And they looked at these groups, most of them had preop chemotherapy. And looking at how they approached it, most patients had a totally laparoscopic approach, but almost 40% had a hand-assisted laparoscopic. You notice there's regional differences or international differences. European surgeons like to do more of a laparoscopic. In the US, we do use more of a hand-assist approach. They showed, again, major hepatectomy-- these are academic centers generally-- almost 46% had major resections. About a 4% conversion rate to open. And overall surgery is little more than three hours. Median blood loss about 200 cc's. About 10% of patients had a transfusion. And they found about almost 95% of patients had a negative margin. There were no deaths. About a 12% complication rate. And the median stay in the hospital about four days. Now if you look at by country, about three days in the US, six days in Europe. Generally in Europe, Asia, places they tend to stay in the hospital longer. And they looked at some overall, long-term outcomes. Five year survival. Overall disease 350 and 43%, which is fairly comparable to series of open resections. There was another study of meta-analysis looking at also liver resection open versus laparoscopic for colorectal liver mets. About 700 patients. And when they looked at all the different perioperative factors-- blood loss, transfusion rate, morbidity, length of stay-- they were all reduced with a minimally invasive approach. And also, the five year overall disease-free survival was comparable between the two groups. And they did forest plots looking at effect on postop morbidity. You can see it tend to favor laparoscopic liver resection. Over here, looking at hospital length of stay, also these studies also tended to favor a laparoscopic or minimally invasive approach. Another entity we talked about before that we operate on is hepatocellular carcinoma. And this was a Japanese study looking at long-term perioperative outcomes. 31 institutions around the country. And what they did here is propensity score matching. There were about 400 so MIS patients, or minimally invasive, almost 3,000 open. And what they did is they matched the patients in these two groups with baseline characteristics, tumor variables, size of tumor, number of tumors, and what kind of procedures. So from these two groups, they matched 387 patients and compared their outcomes. So they were similar in their presentations, similar extent of tumor, similar types of operations. And they found in this group, when they matched it, the blood loss was less with the minimally invasive laparoscopic approach by 150 versus 400. The median length of stay-- again, this is Asia, so you're talking just the baseline hospital stay is going to be longer-- 13 days versus 16 days for the laparoscopic approach. And then again, they have found the complication rate 6.7 versus 13 was also significantly lower. And this shows their survival plots, or graphs, for overall survival and disease-free survival in this propensity matched group. And you can see the survival curves essentially overlap. So they did not see a difference in the overall 1 year, 3 year, 5 year survival rates and disease-free survival. So the cancer, or long-term outcomes, with these approaches were similar. What about robotic surgery? So there's a lot of news about robotics, when you hear about it, at least in surgery, there's a lot of talk. We know it's very well established in prostate, kidney surgery, gyne operations it's fairly common now. We're seeing more work in colorectal surgery, people having robotic operations. And cardio-thoracic surgery it's being done. Otolaryngology, the head, neck, laryngeal sparing. So it is an expanding area of surgery. Hernias are now being done also robotically. So what about the role of robotic surgery for liver resection? Well again, advantages, disadvantages of the robot is the robot does offer, in some ways, better 3-D visualization, better camera control compared to a laparoscopic. If you look at the way it's wristed, it provides better dexterity than maybe a laparoscopic approach. You don't see the tremors. There's not a fulcrum effect of operating with the robot. It does provide better suturing ability compared to laparoscopic as a baseline. And also when patients are operating-- when surgeons operate on the robot, they sit at a console. So it's probably better ergonomics compared to laparoscopic approach, or even an open when you're bending over standing up. What are the disadvantages? You don't have tactile sensation when people use the robot. You cannot feel any kind of pressure. There's no tactile feel. It's all really visualization. The cost is high. I'll talk about that a bit later. You do need a skilled assistant at the bedside. So the surgeon's at the console, they do need someone at the bedside who could help, who is skilled, and has that ability to provide assistance. Also it's not that good for moving around different fields. Once you operate one area of the abdomen, it's hard to move around to another part of the abdomen. And because it is still early, the benefit is still not well-defined in liver surgery. There was a recent review that I'm going to talk about that looked at what's available in the literature and looked at 14 different series, about 440 patients, and compared it to a robotic to a laparoscopic resection. And they also looked at some long-term outcomes, looked at what the costs were again. The patients mainly that they operated on had a hepatocellular carcinoma, colorectal liver mets, and intrahepatic cholangiocarcinoma. About a third of them had a major hepatectomy. And theoretical benefit is, again, that because the robot's increase visual clarity, dexterity, there may be a benefit in complex resections near the hilem or near major blood vessels. This is again, more of a theory, it's not a proven research fact. What they found is the robotic procedures tend to have longer operative times compared to laparoscopic, but it seemed to improve with experience. Overall, the blood loss, transfusion rate, those factors were very similar to a laparoscopic resection. They had a conversion rate of about 7% compared to 4% for laparoscopic resections. Overall, the complication rate, it was 21% compared to 11%, maybe a little higher. Most of these were minor complications. There were no deaths in these series. Length of stay was similar to laparoscopic liver resection. In the US median was about four days. This is more data from the University of Pittsburgh. And in Europe and Asia, again, longer 6 -12 days. Looked at long-term outcome this is where again the follow-up is not that long. So there's pretty limited data on the overall and disease-free survival with robotic resections. Median tumor size is about 6.4 centimeters. And the follow-up is pretty short about 9 by 25 months, 9-25 months. They did not note any kind of port site recurrence as it's always been a theoretical risk of doing laparoscopic surgery in these cancer cases. But none were noted. So the robot, generally, the current system costs about $1.2 million to purchase and the maintenance fees are about $140,000 a year, can be. So there's a big upfront investment, there's a big ongoing investment of robotics. So definitely higher cost than laparoscopic as far as the overall cost of equipment. And so that balances whether that additional cost is worth whatever benefit you might get from a robotic approach. That being said, the robot is here, it's being used. So this is still really being studied at this point in time. I want to talk a little bit about what our experience has been here at Wake Forest with laparoscopic and minimally invasive liver surgery. I started doing a laparoscopic liver resection about 2004. And over this period, that we've attempted about 114 cases of minimally invasive liver surgery. Of those, we converted 13, about 11% conversion rate, and of then 101 resections. The great majority are laparoscopic-assisted, about 75%. And then we have another smaller group of laparoscopic, hybrid, and robotic operations. But you can see here the trend, we divided our experience into quartiles from 2004-2006, 2007-2009, 2010-2012, and then more recently. And we've really see a growth in our minimally invasive resection cases, mostly of laparoscopic-assisted, but other cases as well. These are the primary histologies, or primary sites we are doing. Again, mostly colorectal, and liver/bile duct, benign cases, and then some other selected metastatic sites. OR time's been about three hours, so very similar. Blood loss, median 350. Major hepatectomy is about 11%. So again, small percent of what we're doing, but we're doing some left and right hepatectomies. When you look at segment VI, or VII, and VIII, more central posterior, we are doing more of those and that increases our laparoscopic major hepatectomy rate. And a low transfusion rate's about 5%. Generally it's about one tumor that we're doing, median tumor size is about 3 centimeters. Overall R0 resection rate is 95%. It's comparable to what's reported. And the margin width on average median is about 7 millimeters. Overall complication rate, if you look at any complication including minors, about 41%. But as far as more severe complications, about 13% of patients. Hospital stay on median was four days, again pretty comparable to the literature. And no post-operative mortality in this group. So I just want to end the discussion with a case that we recently did just to illustrate how we use it. This is a 62-year-old gentleman who had Hepatitis C, recent alcohol use, so he wasn't a candidate for a transplant. He had preserved liver function Child's A with a MELD score of 7, all indicating good liver function, preserved liver function. And he had a 3 centimeter mass in the right lobe of the liver that was consistent with HCC. So since we're doing a talk on surgical approaches, or technique, I do have the obligatory surgical video just to show how we approached it. This is just illustrating cirrhotic liver. This is a robotic partial liver resection. And we've opened up-- the tumor's over here on the left of the screen. And this device we're using is a device that seals the vessel and then cuts the tissue. So it's going to the tissue. You see there is some oozing and what we're using on the left hand there is a bipolar device to try to coagulate the bleeds, some of the smaller vessels that were bleeding. As we're moving through-- so it's a combination of using the bipolar here and then the vessel sealer. Essentially that device on the right hand is going to be pushing through and cutting the parenchyma as we move through. So just to move forward, that's our completed resection over on the left. And then, really just shows you the ports. He's got three. Some of these are just markings from anatomy, but he's got one, two, three robotic ports and then an extraction port right here to get that lesion out. So just in conclusion, minimally invasive liver resection it's fairly well-established for minor resections and being developed for major liver resections. And I think the data shows that minimally invasive liver surgery it can reduce complications and length of stay compared to open. The long-term outcomes appear to be similar to open procedures. And I think that as technology improves and experience improves with this technique, we'll see the treatment of more complex and advanced liver malignancies with this modality.

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